Essentially, I’m looking for a reliable, go-to reference that I can consult whenever I encounter a presentation I’m unsure about, rather than having to search through multiple resources.

Hi everyone, I’ve been working at a private practice outpatient clinic for about 5 months. Initially I was seeing up to 20 pts a day, 3x a week, and 1 day for admin, and 1 day for assisted living (about 10 patients). I was able to keep up, even though I didn’t get much formal EMR training (eCW). I have a template for a normal clinic visit and for telemed. I’ve written dot phrases for the most common chronic conditions. I have some order sets but I need to make more… eCW is so slow, and I feel so slow putting orders.

The private practice’s main doctor of 20 years suddenly retired a few weeks ago so now I have become the only full-time doctor. They now book my schedule like an airline 😆They schedule 31-33 patients a day to account for no-shows. I average now about 24-27 patients a day. One time I saw 31. They had to increase my clinic days to 4. Not many procedures but they plan to buy more equipment to do these soon. The numbers come from admin pressure that we NEED this many patients per day to stay afloat. Likely true. We (allegedly) do not have good contracts (‼️).

I am exhausted and falling behind. I know the advice has to “automate” more things, more dot phrases, ai scribe… I was wondering if anyone had more specific advice. Obviously I would love to close all my notes the same day and understand the importance. I am just constantly exhausted, behind, and triaging what’s most time sensitive.

I also have started making my notes extremely short. I think this has probably been the most effective change for me lately… especially after a residency that was obsessed with long notes. 😅🫩

Also I do not have other doctors to rely on for mentorship, and my admin barely know how eCW works. I’ve been doing a lot of tutorials on the support site. I learned so much from my seniors in residency, so being the main doctor for this practice is intimidating and lonely. The one other doctor just joined, is in his 50s, experienced, nice, but is only part time and doesn’t give very specific advice on workflow. I’ll try to keep observing how he does things.

Thank you for your senioring. It’s been awful.

ADDENDUM:
SALARY: I asked for a salary raise last month and they said they would in one month. 🚨

VOLUME: the problem is absolutely the volume. Drink this tea. They said at this time they are making $25-60 a patient because their allowable rates for their current contracts that they inherited from this clinic were terrible. I verified this with the biller and this is indeed true. Yes I am billing 99214 because I always take care of 2 chronic conditions and med mgmt 🏀 and 1-2x a week I do OMT so there you go, a little procedural billing 🏀. Math doesn’t math but also the math is bad. This clinic is a fossil.
- the patients still think a pap is yearly
- the med lists still have glimepiride 6 mg (retired dose)
- ciprofloxacin as first line uncomplicated UTI
Chart review is like archaeology 🔍

EMR: the tech tips really help. Yes at this time I am closing the charts asap so I can 🏃🏻‍♀️

Those of you guys who work at critical access sites what are your hours like. Do you usually cover something like 1 full weekend on call every 5-6 weekends and a night during the week? What’s your schedule like?

New full time outpatient doc, work 4-10hr days, started August. Took over a part time panel and building the rest on my own. Obviously also seeing my other partners overflow, random preops for other PCPs, urgent care stuff where they don’t establish. My salary is locked for a year regardless of RVU. Admin comes to me and “ask” if I would see patients at another office as they’re down two providers so I will be covering one of their on baskets and my own for apparently four months and it’s 15min further from my home. They say there will be compensation but how much should I ask for? This could hurt my RVUs at my home site when I return because it will be four months where I’m not building panel there. What should I be looking out for with this “ask” to protect myself and my home site job because I do love it here?

Hey everyone, I think most of us are aware of a concerning and growing pattern of non-clinicians, software companies and other corporations putting pressure on physcians and nurses, around patient volume or specific treatment decisions.

If you encounter something like this, reporting it can require a lot of documentation. People often think of the medical board first, but it may help to gather the relevant emails, policies, screenshots, contracts, dates, and other records before deciding where to report.

One resource I found is CPOM Report. It helps identify potentially relevant state and federal agencies based on the details you select about the situation, such as the type of complaint, who is involved, and other variables.

Sharing in case it helps someone figure out where to start.

I’m a physician building a small SNF/post-acute practice using part-time/PRN employed physicians and NPs/PAs. The practice handles billing, malpractice, EMR, and administrative support. Cash flow is limited while patient volume ramps up.

For people who run or work in similar groups:

1. What is reasonable clinician pay per encounter? I’d especially appreciate actual examples for 99309 follow-ups and 99306 admissions, separately for physicians versus NPs/PAs. Do you use fixed CPT rates, a percentage of collections, or a minimum plus incentives?

2. How much should the practice retain? What percentage remains after clinician compensation, and what is a reasonable actual profit margin after billing, malpractice, employer taxes, software, support staff, and coverage costs? How does that differ for physicians versus APPs?

3. When do you pay clinicians? Regular payroll after encounters are signed/submitted, or after collections arrive? If collections-based, how do you handle the delay, guarantees/draws, denied claims, and downcoding?

4. What should billing and EMR cost? What billing percentage or minimum is reasonable, what services should it include, and which systems work well for a small group rounding across multiple SNFs with occasional PRN clinicians?

5. How much cash reserve would you want before hiring, and what minimum census makes adding a clinician worthwhile?

An anonymized example would help tremendously: clinician type → CPT → actual collection → clinician pay → practice costs → amount remaining.

Thanks—especially interested in real SNF/post-acute experience.

When they decline CBT-I, of course…

I was an Lpn at an FQHC for about three years. Unfortunately they closed due to not seeing enough patients. The doctors have turned it into “family med” that is more focused on weight loss, anti aging and concierge care. I feel like I’ve seen this pattern with a lot of family clinics. Is it just because family medicine isn’t profitable enough and not enough people have the resources/insurance to see a family doctor anymore? I kind of hate this shift. I feel like it’s fueling the issue of patients only caring about how they look, not how their health is actually faring and we need just good basic family medicine out there

Hi all. Looking for some advice for an adult patient of mine who has aged out of our children’s hospital specialists. I am having trouble getting anyone (especially GI) to help me in managing tube feeds, as he is prone to periods of intolerance. GI has offered no assistance themselves nor offered any referral to a dietician within their practice. Any advice on a direction to go with this?

I’ve looked into Nourish for them. They have Medicare so too expensive.

My system doesn’t really have a good setup for in house dieticians that are well versed in outpatient parenteral nutrition.

I’ve tried to get a hold of the home health company that provides his tube feeds. Not getting anywhere.

A patient comes into urgent care with a red, swollen leg. Cellulitis or DVT?

It’s a familiar presentation, and deciding who needs further testing can get tricky during a busy shift. I created this short video to walk through a practical approach. If you’re working in urgent care, I hope you find it useful!

▶️ Cellulitis or DVT? The Urgent Care Decision Framework
Cellulitis or DVT? The Urgent Care Decision Framework

What tests do you have access at your facility to assess the red hot swollen leg? We are able to order a DDimer where I work, but it would probably be a false positive anyways if it's cellulitis :/

Are we behind the times and just now documenting every sample we give out? This is new in our office and it seems like such a pain in the ass to go doc the lot number etc on every box of nurtec for example.

This is including pre-charting, notes/documentation, inbox, labs, refills, orders, forms, referrals, and other admin tasks

I have a patient with lumbar radiculopathy who is post-laminectomy. She is followed by pain management. She used to be on Norco and failed a drug screen, which was positive for marijuana and benzos. Her prescription was changed to tramadol and she was started on Cymbalta and Lyrica. Epidural steroid injection done recently with no benefit. She’s being seen by Behavioral Health. She has written extensively through my chart to the pain management doctor berating him for not taking her pain seriously. She saw me today and I explained that if I were to write her a controlled substance, she would be discharged from the pain clinic. The pain clinic is county run and she doesn’t have any insurance to go anywhere else. I added a muscle relaxer to her regimen and encouraged her to apply for disability; after our appointment, she sends an email accusing me of being judgmental and not helping her and just being a terrible doctor. .I do not want to get into a discussion over my chart. How do I handle this patient? I certainly don’t want to hamstring the pain management provider, and I definitely believe she is in real pain, but I do think she is manipulative.

Wondering if anyone can share some updated insight for non ob fam med practice in Pacific Northwest. Looking for some hard numbers if possible. Thanks!

I’m tired fam.

Been seeing covid, flu and respiratory viruses blow up all September and October.

I’m tired of the constant demand for an instant fix.

I’m tired of the day 2 sinus congestion stating they have sinusitis and need ABX and because they always get a sinus infection.

I’m tired of the “I can afford to be sick this week won’t a Z Pack help”

I’m tired of the mild cough demanding a 6th course of Steroids this year because “if they don’t get them it settles into the chest and turns into walking pneumonia”

I’m tired of the bounce backs 1-2 days after initial visit because they “aren’t better yet and OTC isn’t working” (it’s day 4 of flu…)

I’m tired of the messages asking for “more antibiotics to kick it as the first didn’t work, No I won’t come in again can’t you just send more”

I’m just tired. And it’s only October…

Signed, Urgent care.

Partially rhetorical question because I keep seeing other providers giving it out like candy and I don’t really understand why because it’s not indicated first line for most things….?

30yo New to attending life, but I still managed to secure over 400 K on my first year as a 4d ww outpatient PCP in the NE. I am by no means used to having all of this disposable income and I wanna make sure I don’t waste it curious to see how everybody has structured their finances and if there are any gaps in my current plan.
413k w2 income
401(k) maxed with match 24.5k
HSA Maxed 4.5k
Back door Roth maxed 7k
No kids so those tax advantage accounts are not available
No mega back door available
45K in savings which is a 7mo runway for me of fixed expenses.
I do have a 250k student loan at 3.2% and a car loan at 5.5% which I don’t mind holding, because I’d rather get into a few markets early
No mortgage

Had my fare share of travel this year hitting Japan x2 Morocco Florida, East Coast, West Coast, Mexico, and four countries in Europe. Bought a car and a few watches. I gift about 5% of ea paycheck to friends and family thru different means.
Saving for a wedding but I should be able to get through that as well.

Still sitting with the final 70k that just hit my acc.

My question is, should I buy a house even though I’m a happy renter? Should I put my money in a regular brokerage account? I don’t wanna be overly exposed to just the stock market. I’m 90% ETFs 10% bonds. I’m thinking into some real estate at this point because I can throw 30% into 350 K three bedroom apartment in an upcoming neighbourhood make it my primary residence and ride that for five years and see how that goes. I think I might start diversify my savings with 5% of savings as gold.
I’m also getting married to someone in the same financial situation as me so the problem is about to double but I’m curious to hear what people have done that has worked for them and if there are any gaps in my plan
First problem to have I’m definitely very thankful for the situation

No idea if I want advice or just to rant as Im just feeling frustrated/ questioning if I made the right choice taking this job.

New attending at a large hospital owned practice. I am essentially taking overflow from all the docs in our healthcare system including my practice as well as nearby practices. Press Ganey scores are affecting me more than they should. Ive gotten mixed reviews from patients saying how much they loved me and switched to me as PCP to horrible reviews because their PCP was booked out months in advance and they had to see me aka not their PCP (so negative review has nothing to do with me but still attached to me) or because I wouldn’t give them antibiotics for their 2 days of runny nose/post nasal drip. I would be fine with this if it ended with the survey but our manager prints all the reviews out weekly and displays it out for literally everyone to see. As a new attending, I feel like it has crushed my spirit honestly and affected my mental health. Im already anxious and trying really hard to practice evidence based medicine but I feel like I work at Burger King where the motto is always “have it your way” regardless of whether that is medically necessary or not. Im also getting overloaded with preop clearance visits for patients I have never seen before and have limited information about. I’ve verbalized how inappropriate I feel this is as these patients should be cleared by their PCP who knows them. Ive relayed my concerns to management but feel like they talk around it in circles without any meaningful change.

Hear me out. I’ve got a 60 yo patient with CKD 3b which has been pretty stable for 5+ years. She sees nephrology so maybe i just need to mind my own business. But over the years, i have never seen her nephrologist check her microalbumin to creatinine ratios. With as much as i have learned about albuminuria I am tempted to order UACRs and then treat with sglt2 if indicated. Already on ARB. Am I overstepping my bounds as her PCP when she already follows with nephrology?
No judgement against her nephrologist but this particular physician is famous for the 30 second appointment, is super hard to get on the phone and once i finally make contact is already saying goodbye before i can even ask a question. No doubt this nephrologist knows what they’re doing, but I just want to give some context.

Well, I had very little confidence in the US healthcare system going into today, but I just lost some more.

I work at a facility where people stay longer-term.

This morning at around 9am I sent an otherwise healthy 36yo F to the ER with 8/10 abdominal pain and 5 episodes of large volume emesis within like 90 minutes. I call and give hand off, pretty straight forward rule out acute abdomen.

Around 3pm I get a call that they are sending her back. I ask to talk to the doctor taking care of her and got connected with an NP. She started off by telling me that her CBC and CMP were normal except for a mildly low white count that she was attributing to a “viral response” and that she felt better after 1L of IV fluids and then kind of stopped talking.

So I asked what her imaging showed. Turns out no imaging was done because she was “no longer having abdominal pain” evidenced by the fact that she could “crawl to the bathroom and back to bed just fine.” (yes, she used the word “crawl”)

I then asked about lipase and she said she “didn’t get one because her liver tests were stone cold normal.” I actually had to say “lipase is for the pancreas not the liver.” She said “yeah but if it was her pancreas her liver labs would be elevated too.” I said “well…no…not necessarily…” and she was like “I’ll add on a lipase.”

I asked if she passed a PO challenge and she said she gave her a popsicle but didn’t know when the last time she vomited was because it “wasn’t documented.” I told her that the nurse I work with had talked to the nurse she works with earlier in the afternoon to get an update and at that time she had vomited within the hour, around 1pm. The NP replied that that was “news to her.”

The more I’m talking to this woman the more horrified I am. She got Tylenol for complaints of a headache but no medication for nausea or vomiting. She did not do a pregnancy test. She was there for 6 hours and all she got was a CBC, CMP, EKG, Tylenol, a popsicle, and 1L of IV fluids.

How did we get here? How is this woman allowed to practice independently?

Do any of you prescribe repatha (patients either intolerant or not meeting goal with statin/zetia/bempedoic acid). At my place no PCP prescribes repatha and patients are refer to cardiology. It seems we prescribe other medications with higher risk but repatha is where some seem to draw the line.

I still can’t find a good reason for this. Had a 51 yo with hyperlipidemia, uncontrolled hypertension tell me that he could never consider a statin because of how much damage they do to the body. Meanwhile this dude has been on hydrocodone 10 mg QID from pain management for the entire 5 years i have seen him and recently started IM testosterone at a local hormone clinic.
Is this all just fear mongering or are the increased risks of dementia, accelerated diabetes, etc really legitimate? I assumed statins got a bad wrap cause of the relatively high frequency of myalgia, arthralgia, fatigue but so many patients view them as actually toxic and sinister!

Hello everyone!

I'm a visa-requiring IMG applying for the 2027 Family Medicine Match, and I'm getting increasingly concerned about my application.

My profile:

- Graduation year: 2023

- Step 2 CK: 26X

- Step 3: Result pending, hopefully coming next week

- USCE: 4 months of observerships

- US LORs: 3 Family Medicine letters

- 3 Family Medicine observerships

- Clinical experience: 3 years post-graduation

- Currently a PGY-2 resident in General Medicine in my home country

- Applying exclusively to Family Medicine

- Applied to 94 FM programs

- Visa-requiring IMG

Unfortunately, I haven't received a single interview invitation yet. I've noticed that other visa-requiring IMGs are receiving interviews from some of the same programs I applied to, which has made me wonder whether there's something I can still do to improve my chances.

I've also sent letters of interest to my signaled programs but haven't received any responses so far.

At this point, I'd really appreciate some advice:

1. Is it still too early to be concerned, or should I be worried about having no interviews?

2. Could my pending Step 3 result be affecting my chances?

3. Is there anything else I can do at this stage to improve my chances of receiving interviews?

4. Would sending letters of interest to additional programs be worthwhile?

5. Given my profile, is there still a reasonable chance of receiving interview invitations?

I'd really appreciate honest feedback and suggestions from applicants in a similar situation or anyone who has experience with the residency application process.

Thank you!

Curious how any of you all would approach this situation. I have a patient in her 60s with ESRD who is also on chronic opioid therapy with difficulty weaning off the opioids due to legitimate post traumatic pain. Her insurance apparently dictates that Mayo is the only place she can go for a transplant. Mayo rejected her for a transplant since she's on chronic opioid therapy. Tried to send her to a local transplant center and she was refused since her insurance prefers she goes to Mayo. Do I tell her to suffer with the pain and come off opioids just so she can get a new kidney? Plead with her insurance to let a local team do it? Plead with Mayo to give her a new kidney without making her suffer severe uncontrolled pain? Just leave her on dialysis for the rest of her life?

Obviously my multimodal pain options are extremely limited with her kidney disease. Already has lidocaine patches, every other day duloxetine, and tylenol. Had swelling with gabapentin and lyrica. Would switching to suboxone be an option or would she still be denied since this is still an opioid? Thanks for your thoughts!

I’ll preface this by saying I’m a smidge low on patience since I’m approaching 31 weeks pregnant with twins lol. That being said, I’m an introvert by nature anyway.
Anywho, my new office has drug reps here for breakfast or lunch 2-3x a week. They inevitably want to meet “the new doc”. Problem is, during my 1 hour lunch all I want to do is hide out and take that time to decompress. I want to chill on my phone, eat, maybe even catch a quick snooze. I also only live 5 mins from clinic and like running home sometimes. I don’t eat the food they bring (I bring lunch and eat breakfast at home). So…. How bad is it to hide from most of them? The other docs/PA/NPs interact with them but they also eat the food they bring. Am I overthinking this? 😅